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Monday, October 29, 2012

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A woman with devastating, unrelenting eye pain and photophobia presented to Perry Rosenthal, MD, after being dismissed by a number of other physicians. First she had seen two different ophthalmologists, who found no supporting signs for her pain and recommended psychiatric treatment. The psychiatrist recommended a pain specialist, who said she suffered from corneal neuralgia and referred her on to a cornea specialist, who, in turn, told her there is no such disease. Finally she found Dr. Rosenthal, who is an assistant professor of ophthalmology at Harvard Medical School and scientific director of the Boston Foundation for Sight. Dr. Rosenthal is on a mission to teach fellow ophthalmologists that such patients may suffer from corneal neuropathic disease. Their pain is real, he said, and it can be excruciating.The power of corneal pain. The cornea is the most powerful pain generator in the human body, said Dr. Rosenthal. The density of corneal pain receptors has been estimated to be 40 times that of dental pulp. He explained that the damaged nerve fibers in the cornea, the sensory fibers, cause all the symptoms, whether or not the initial disease is severe dry eye or corneal neuropathy.
The intensity and constancy of corneal neuralgia can be incapacitating and even induce thoughts of suicide, said Stephen C. Pflugfelder, MD. Dr. Pflugfelder, who is professor of ophthalmology and director of the Ocular Surface Center at the Baylor College of Medicine in Houston, had a patient with so much corneal neuropathy following LASIK that he begged to have his eyes enucleated.Dry eye or neuropathy? Unfortunately, in mild cases, the symptoms, if not the signs, for dry eye and corneal neuropathy can be identical. The same sensitivity to evaporation, wind or dry environments that exacerbates classic dry eye also increases the neuralgia. Patients report severe, unremitting, burning pain and photophobia, Dr. Rosenthal said. Some can’t stare at a computer screen without pain.
“Ophthalmologists have never been able to explain satisfactorily why many patients who complain of dry eye symptoms don’t have dry eye,” said Dr. Rosenthal. “We have been misled by the term dry. Dry eye sensations are nonspecific symptoms of corneal pain. The question then becomes: ‘What can cause dry-eye-like pain other than dry eyes?’ The only logical answer is corneal hyperalgesia. We’ve been asking the wrong question and have been targeting the wrong disease. Neuropathy explains it.”Diagnosis
Unexplained corneal pain has confounded cornea experts for decades. And when the pain doesn’t respond to dry eye treatment, doctors tend to dismiss the patient, Dr. Rosenthal said. “These patients need special care. These are some of the most devastated patients and they have been marginalized.”
Many ophthalmologists are not prepared to identify, let alone treat, corneal neuropathy, in part because they haven’t been trained to think beyond objective findings noted on slit-lamp examination. “Ophthalmologists may not easily diagnose these patients because there is no clinical correlate on exam,” said Pedram Hamrah, MD. “I have seen many patients whose symptoms have been dismissed by physicians. But their symptoms are real. We can actually help these patients and relieve their symptoms.”
Dr. Hamrah, who is assistant professor of ophthalmology at Harvard Medical School and on staff in the corneal and refractive surgery service at the Massachusetts Eye and Ear Infirmary in Boston, became interested in corneal neuropathy when he started seeing exactly those patients who had been dismissed by other doctors. “We began studying corneal nerves in these patients with the in vivo confocal microscope, which has a resolution up to 1 µm, and saw nerve abnormalities. In ophthalmology, we are mainly trained to treat what we see. But you can’t see the nerves with a slit lamp.”
Jayne S. Weiss, MD, professor of ophthalmology and pathology at Kresge Eye Institute in Detroit, recalls such a case. A young man presented to her with excruciating corneal pain and evidence of a healed lamellar keratotomy. “Confocal microscopy revealed abnormal collections of unusually tortuous corneal nerves consistent with corneal neuropathy. Although vision eventually recovered to 20/20, the patient had asked at one point if he could have retrobulbar alcohol injected to dull the pain,” she said.
Dr. Weiss cautioned that while some patients with severe pain have indeed been wrongly dismissed, no one has quantified how often this happens. “I think corneal neuropathy exists, but it is not well-defined, and we must be careful to not to think that every patient with pain and a normal slit-lamp exam has neuropathy. I consider the neuropathy diagnosis as requiring unusual pain, a normal-looking cornea plus abnormal confocal findings.”

Checklist: Dry Eye or Neuropathy?

CLASSIC DRY EYE. Patients with dry eye have irritation symptoms, such as foreign body sensations, burning and reflex tearing. On slit-lamp examination, the tear film may appear unstable or there may be decreased tear meniscus. In more severe dry eye, there may be fluorescein staining of the cornea and dye staining of the conjunctiva.TEAR DYSFUNCTION WITH EXCESSIVE SYMPTOMS. Be suspicious of neuropathy when the presentation seems to be classic dry eye but the symptoms are way out of proportion to the dry eye presentation, Dr. Pflugfleder said. It’s still worth treating it as classic dry eye to reduce the pain, and about half of all patients respond to the point that symptoms are tolerable. For the nonresponders, however, neuralgia has to be addressed, he said.CORNEAL NEUROPATHY. “Whenever you see a patient with dry-eye-like symptoms without equivalent signs, assume that is corneal neuropathy until proven otherwise,” Dr. Rosenthal said. “Corneal neuropathy is a disease in its own right regardless of tear metrics.” Triggers include an episode of zoster keratitis, diabetic neuropathy, chemotherapy, Guillain-Barré syndrome, isotretinoin (Accutane) treatments, recurrent corneal erosions and exposure to noxious fumes or radiation.

Treatment
Dr. Hamrah recommended treating the pain of corneal neuropathy palliatively and then sending the patient to a cornea specialist at a tertiary referral center who can perform scanning laser confocal microscopy and treat the underlying condition. Dr. Pflugfelder agreed: If the patient does not respond to the standard dry eye treatments, then the physician must look for other causes of pain, he said. That means looking for nerve abnormalities, either in loss of density or increased tortuosity, or branching with laser scanning confocal microscopy.Try improving everyone’s tears. Whatever the etiology—dry eye or neuralgia—Dr. Hamrah recommends starting with artificial tears. When those are ineffective, the fluid reservoir of a nonfenestrated scleral lens can insulate the corneal surface from the stimuli of a hostile environment, Dr. Rosenthal said. The Boston Ocular Surface Prosthesis (formerly the Boston Scleral Lens), developed by Dr. Rosenthal, is a fluid-ventilated gas-permeable contact lens that rests entirely on the sclera, creating a fluid-filled space over the diseased cornea. The lens covers the entire corneal surface, bathing it in fluid, and may provide relief for the neuropathy.Then treat beyond the symptoms. For patients who do have neuropathy, treatments that increase the tear layer are palliative at best and don’t get at the underlying disease, Dr. Rosenthal said. After hydration of these severe dry eyes over a period of days, their surfaces can heal and look perfectly normal, but the patient still may complain of dry eye symptoms, suggesting the presence of neuropathy.
Dr. Rosenthal believes the persistence of pain in the presence of a liquid bandage suggests that dysfunctional pain-generating sites are discharging spontaneously. In these cases, treatment must directly target the dysfunctional corneal nerve terminals and ectopic firing sites. In the past he has had success treating these patients with dilute, sub-hypoesthetic concentrations of local anesthetics in the fluid reservoir of the scleral lens. But more recently Dr. Rosenthal has used the new antiepileptic drug lacosamide. It has the ability, he said, to modulate overactive pain firing sites even though it has no anesthetic properties, adding credence to the notion that the pain is neuropathic. Dr. Rosenthal acquires lacosamide as a topical preparation compounded by Leiter’s Pharmacy and Compounding Center (San Jose, Calif.). “When used as 1 percent eyedrops— the basic concentration used for IV use—it’s effectiveness lasts only 15 to 45 minutes, whereas that same concentration used in the fluid reservoir of our scleral lens can last as long as the patients’ waking hours.”
Unfortunately, some patients are resistant to lacosamide, perhaps due to maladaptive plasticity in the pain signaling pathway, Dr. Rosenthal said. In these cases, treating the cornea alone is insufficient since much of the pain originates in the trigeminal ganglion and brain, making it a form of phantom pain. Treatment might warrant other systemic anticonvulsants, like gabapentin, pregabalin or carbamazepine. But their effectiveness can be sporadic.
Dr. Pflugfelder agreed. Gabapentin and similar drugs may be used to blunt sensory nerve stimulation or the perception of nerve stimulation, but it doesn’t always work and it has side effects. “Unfortunately, I don’t think any of us have a good treatment,” he said.
“A small percent of patients develop this problem post-LASIK. If a patient presents with chronic pain following LASIK without signs of tear dysfunction, confocal microscopy may reveal evidence of abnormal nerve regeneration. Some patients with this may respond to autologous plasma drops to stimulate nerve repair or the Boston Ocular Surface Prosthesis,” Dr. Pflugfelder said.
In the meantime, Dr. Rosenthal has been trying to reverse maladaptive brain plasticity with Scrambler Therapy (Delta). This uses transdermal transmission of encoded electrical signals that are interpreted in the brain as “no pain.” The treatment works dramatically in some patients; in others not at all, he said.What Ophthalmologists Can Do Now
“Doctors should understand it’s a problem,” Dr. Pflugfelder said. “You should not write these patients off as being hysterical. If they don’t respond to the standard dry eye treatment, refer them to a cornea specialist, but one who has familiarity with this problem.”___________________________

None of the physicians interviewed report financial interests related to the story. Dr. Rosenthal is the founder and an employee of the nonprofit Boston Foundation for Sight but has no financial interest in the Boston Ocular Surface Prosthesis.

I have been studying dry eye for quite a while at this point.
Dry eye is one of the subjects that follow the rule. The more I know about this subject, the less I actually know.
At one point you think that artificial tears are the best you can do. Next you think punctal plugs are the "sure answer". Somewhere along the line you try Restasis Lotemax and even the obvious Lacrisert.

What I have found most interesting it the TearLab. What it tells us is that the symptoms do not correlate with the actual tear osmolarity. You can have patients who are miserable and have normal tear chemistry.
You can have patients who are totally asymptomatic and yet have what can only be classified as "severe" dry eye.
Lately I have been speaking to patients all over the world. Australia, Canada, Sweden etc.
They have a common problem. Extreme discomfort with no help in sight.

Some have asked me to open this blog up as a forum for them to speak directly to me as the Dry Eye Talk keeps a tight leash on professionals. It is almost as if they don't want to help the patients who are absolutely miserable.
I will take a peak at this site form time to time. If we get some activity, that will be great. If not, there won't be any difference since the blog has been up.
So, let me know if you have any questions.

5. Choose the appropriate treatment and duration of treatment for amblyopia.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Abbott reported serving on the Board of Directors of OMIC, and Dr. Chang reported a consulting agreement with Advanced Medical Optics, Inc. Drs. Rutar, Margolis, and Horton, and the planning committee reported nothing to disclose.

Acknowledgements

Lectures for this program were recorded at Ophthalmology 2008, held December 12㪥, 2008, in San Francisco, CA, and presented by the University of California, San Francisco, School of Medicine, Department of Ophthalmology, Beckman Vision Center, San Francisco, CA. The Audio-Digest Foundation thanks the speakers and UCSF School of Medicine, Beckman Vision Center for their cooperation in the production of this program.

Povidone Iodine for the Treatment of Bacterial Keratitis in Children Tina Rutar, MD, Assistant Professor, Department of Ophthalmology, Pediatric Ophthalmology and Strabismus, University of California, San Francisco, School of Medicine

Strategies to decrease blindness caused by corneal scarring: eliminate predisposing conditions; vaccinate against measles; encourage use of protective eyewear; educate to reduce use of harmful traditional medications; provide prophylaxis for ophthalmia neonatorum to all newborns

Povidone iodinetreatment for infectious keratitis: effective in preoperative preparation; in ophthalmology, also effective for postoperative prophylaxis, prevention of ophthalmia neonatorum, and treatment of bacterial conjunctivitis

Primary outcome measure: probability of cure depended on rate of cure (closed epithelial defect with minimal conjunctival injection) and time to cure; other measures included rates of improvement, worsening, and failure

Results: 71% of children treated with povidone iodine achieved cure (vs 44% with antibiotics); cure or improvement seen in 82% of children treated with povidone iodine, compared to 89% with antibiotics; cure achieved in 6 days with povidone iodine vs 7 days with antibiotics; worsening on treatment observed in 1 child who received povidone iodine; 1 child failed treatment with ciprofloxacin

Outcome: in study including all 172 participants, patients treated with povidone iodine did as well as those treated with antibiotics

Other differences between children and adults: order of prevalence of bacterial species (ie, Pseudomonas, Streptococcus pneumoniae, and Moraxella in pediatric patients; Moraxella, Pseudomonas, and Streptococcus in adults); ulcer characteristics—pediatric patients had smaller stromal defects and hypopions than adults

I have long treated my patient's eye infections with Betadine. It speeds up the treatment. I recommend this to all of my patients.

Friday, July 20, 2012

New research confirms elevated tear osmolarity (increased salt in the tears) causes dry-eye surface disease. In an article published this month in Eye & Contact Lens Luo, Li, Corrales and Pflugfelder demonstrate that ocular surface inflammation in dry eye is caused by elevated tear film osmolarity. Click HERE to read this important article.

Some had believed that there was a direct inflammatory attack on the eye surface independent of the decrease in tear production or increase in tear film evaporation that is characteristic of dry-eye disease. We now know this is untrue.

I had the opportunity to write an editorial on this paper that highlights the important treatment ramifications of this research. Click HERE to read this editorial.

Saturday, March 17, 2012

So, I procured this item and thought to myself, of what use is such an item?

First I want to tell you that a great many patients who clearly suffer from symptoms of dry eye do not truly have dry eye. The tear lab clearly shows what patients have a lack of tears and what patients do not.

The only benefit I can see from the product would be if once measured, I could prescribe a new treatment and see a change. The change would need to be shown in a numeric fashion.

This device clearly does that. It is repeatable. I have also added a new drug to my formulary. It seems to clearly make a difference in dry eye patients. I will not go into what the drug is, but suffice it to say that it is much better than any other on the market. I hope to explore these novel treatments in greater detail in the future.

Sunday, February 12, 2012

Sunday, January 22, 2012

A recent "Industry News" article in the AOA News (http://newsfromaoa.org/2011/11/06/new-allergan-survey-shows-48-have-dry-eye-symptoms/) caught my attention and continues to intrigue me. The article reports several very interesting facts indicating unmet dry eye need including: 1) Nearly half of all U.S. adults (48%) experience one or more dry eye symptom(s) regularly; 2) 19% of women age 55 and older have experienced dry eye symptoms for more than 10 years, 3) 69% who experience one or more dry eye symptom(s) have not visited a eye care professional to treat symptoms; and 4) of those who visited an eye care professional to treat their dry eye symptoms, 19% visited more than once before finding relief, and 22% reported that they still have not found relief.

My bottom line summary of this market research indicates that there is more unmet need in dry eye disease than likely any other ocular condition. Potential patients self-treat (with or without clinician), experience significant visual and quality of life issues due to dry eye, and have not found substantial relief from the condition. Therefore, ask about symptoms, examine for dry eye, actively manage dry eye and lid disease, and hopefully make a difference.

Tuesday, January 10, 2012

In all my years of being an optometrist I have never given much thought to vision therapy. Many years ago at several meetings I saw a device known as a colorymeter. Kind of a funny looking device it was a plywood box with a light inside and several knobs outside.The premise was that as the patient looked into the box the doctor changed the color of the light shining on the reading material. I could not figure out how I would decide which lens to use. After many years, I once again came across the company. This time the promise was that the doctor would introduce each lens in front of the patient's eye demonstrating two choices and narrowing the possibilities from 16 to 8 to 4 to 2 to one. This lens was placed into a trial frame and the process is repeated in the other eye. Finally with the two lenses in place the patient reads with and without the glasses to see if there is any improvement. I have been amazed! Many individuals increased 50%.